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1. Wait until you are in the presence of a certifying individual to sign this form. Identification may be required. 2. Acceptable certifying individuals include authorized employees of insured depository institutions and corporate central credit unions. Certification by a notary public is NOT acceptable. 3. Mail the completed authorization form to Department of the Treasury, Bureau of the Public Debt, P.O. Box 7015, Parkersburg, WV 26106-7015.
I submit this account authorization pursuant to the provisions of 31 CFR Part 363. I understand that my TreasuryDirect account will be activated upon receipt and approval of this authorization. Under penalty of perjury, I certify the information provided is true, correct and complete.
Social Security Number
Instructions to Certifying Individual: Name of person who appeared and date/place of appearance must be completed. I certify that appeared before me this and signed this authorization.
Signature and Title of Certifying Individual Printed Name and Title of Certifying Individual Name of Financial Institution Address City/State/ZIP Code Telephone
Name of Person Who Appeared
whose identity is known or proven to me, personally at
Financial Institution’s Official Seal or Stamp (such as Corporate Seal or Signature Guaranteed Stamp).
PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE. We’re asking for the information on this form to assist us in processing your securities transaction requests. Our authority comes from 31 U.S.C. Ch. 31 which authorizes the Treasury Department to borrow money to pay the public debt of the United States. Also, 26 U.S.C. 6109 requires us to use your SSN on certain forms when we report taxable income to IRS. It’s voluntary that you provide the requested information, but without it, we may not be able to process your transaction requests. Information concerning your securities holdings and transactions is considered confidential under Treasury regulations (31 CFR Part 323) and the Privacy Act. However, the following routine uses of this information may include disclosure to the following persons or entities: agents and contractors who help us manage the public debt; others entitled to the securities or payment; agencies (including disclosure through approved computer matches) determining eligibility for benefits, finding persons we’ve lost contact with, or helping us collect debts; agencies for investigations or prosecutions; courts, counsel, and others for litigation and other proceedings; a Congressional office asking on your behalf; and as otherwise authorized by law.
We estimate it will take you about 5 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of the Public Debt, Forms Management Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to the correct address shown in the instructions.